Thursday, August 11, 2011

Public Health, Private Interests, HIV and Circumcision

If you don't have time to read the articles below, or even this blog post, take a look at this BBC video. An effervescent medical device industry executive positively drools over their latest offering: an elastic band that fits over a plastic ring, used to circumcise men without the need for surgery, or even anesthetic.

The same executive might not feel so comfortable about a similar device for circumcising women. Of course, circumcising women is a revolting practice with no medical benefit. But rates of HIV tend to be very low among African tribal groups which practice female circumcision. And reducing HIV transmission is, ostensibly, the main reason for circumcising large numbers of men.

Even circumcision enthusiasts don't know why male circumcision appears to reduce female to male HIV transmission during heterosexual penile-vaginal intercourse (although it may increase male to female transmission, which is generally far more common in African countries). They are as much in the dark about any protective mechanism as they are about the value of female circumcision in reducing HIV transmission.

But their enthusiasm for carrying out the operation on millions of men, as people continue to die of diseases that can be prevented for a fraction of the cost of a circumcision, remains intact. Thankfully, Malawi has decided that the evidence for mass male circumcision is not convincing, but many African countries have bought into it.

Apparently in South Africa, where HIV transmission rates among circumcised men are still alarmingly high, 'sexual behavior has not changed', despite those having the operation receiving rigorous counseling and other 'prevention' training. Up until recently we were told how sexual behavior needed to change because men were so brutal and women were so vulnerable.

So the behavioral norms that were considered so horrifying at one time and were considered to 'drive' HIV epidemics are no longer horrifying?

Even the WHO suggests that about 16 people may need to be circumcised to prevent one HIV transmission over a period of ten years. That's a hell of a lot of circumcisions required to make a small dent in Southern and East Africa's high and medium prevalence epidemics. And that's if it actually has any positive impact at all in the long run.

But one of the most worrying aspects of the whole circumcision charade is the fact that it all seems to be stoked up by people who are not themselves at any risk of being infected by the virus or even of being corrupted by the behavior that is said to spread the virus. And their evident zeal is only sometimes stoked up by a desire to make lots of money, though I'm sure that helps.

It has been pointed out that in the case of another 'prevention' strategy, pre-exposure prophylaxis (PrEP), an estimated 45 people need to be taking antiretroviral drugs in highly profitable (for the pharmaceutical industry) quantities to prevent a single infection. Are mass male circumcision campaigns and PrEP really aiming at public health, or is there something else behind them?

While there is a lot written about HIV positive people engaging in 'criminal' behavior and the various legal instruments being discussed to curb such behavior, there has been less talk about crimes being committed against people in the name of reducing HIV transmission, or even various other diseases. In Kenya, quite a few people were put in prison for refusing to take their TB drugs in the last couple of years.

In Nigeria, people have been threatened with prison for refusing to immunize their children against polio. It's not always clear why some people resist polio vaccinations so strongly, but there is a hint that people want more than just a routine injection, for example, clean water and sanitation, a decent level of nutrition, even treatment and prevention for far more common ailments.

This is the country where Pfizer has had to pay out tens of millions of dollars in compensation for causing widespread deaths and disability during a drug trial that went wrong (Trovan). No one in their right mind has any reason to trust pharmaceutical companies, least of all Africans, who are often not even the beneficiaries of the drugs that are tested in African countries.

People have legitimate fears about public health interventions. It's very sad to see people dying unnecessarily, but they should have the right to question what they are being told, the right to be educated, not just compelled. And they should have the right to be told the truth about the diseases in question, as well as the intervention that is being imposed.

So far, people are not being told the truth about HIV or about mass male circumcision. HIV is not always spread sexually and mass male circumcision campaigns can have serious consequences, such as infections with other diseases and even the failure of the campaign to achieve a meaningful reduction in HIV transmission.

We don't know if those HIV positive people who refuse antiretrovirals in a test and treat program might one day be criminalized. Many who refuse are already stigmatized and persecuted. Similarly, if PrEP was available for everyone considered to be at risk of HIV infection, would those who refused to take it be criminalized (or just publicly shamed)?

Supposing UNAIDS did decide that mass female circumcision of some kind was the best way to reduce HIV transmission, or that such a campaign would complement other reduction programs? Would everyone accept the various opinions, data, cajoling and railroading, as many are doing with male circumcision, PrEP and various other public health campaigns? So why do we accept some interventions and not others that may be equally well supported by 'evidence'?



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